KNOWAutism Foundation Tuition and Therapy Assistance Application Form

Tuition and Therapy Assistance Application

The KNOWAutism Foundation Tuition Assistance Program is offering scholarships to individuals with autism who live in the Greater Houston Area and who are attending a special needs school, special needs program, or therapy clinic. Families applying for the first time are given preferential consideration, but families may apply one time every twelve (12) months.
Eligibility Requirements

The family must reside in the Greater Houston Area (in one of the following counties: Austin, Brazoria, Chambers, Fort Bend, Galveston, Harris, Liberty, Montgomery and Waller), demonstrate a need for financial assistance, and provide relevant information for the committee to review. Applications must be completed by the parent or legal guardian of the dependent/scholarship applicant. There is not an age limitation for the scholarship recipient as long as the services fall within the scope of the scholarship, the individual has an autism spectrum disorder diagnosis and will be attending one of the following: a designated private special needs school/or certified special education program, speech therapy, occupational therapy, physical therapy, Applied Behavior Analysis (ABA) therapy, food therapy, PRT, or DIR. We do not fund day care. If you are applying for a different type of therapeutic assistance such as art, music, equine, etc., please complete the Special Interest Program application. If you are seeking assistance for more than one dependent, a separate application must be submitted for each individual. Parent/Guardians must provide documentation of an ASD diagnosis. This may be in the form of a diagnostic assessment or report, copy of IEP, SSI or Medicaid determination letter, documentation from school district, or other similar documents. Scholarships are only awarded one time every 12 months. Services requested must fall within a 12 month period. Review Process: The Program Committee reviews applications a few times a year and selects a limited number of applicants to receive financial support scholarships. A member of the committee may contact you to request additional information or documentation, if needed. All applications and documentation provided remain confidential during the review process. If you are selected to receive a financial support scholarship, a committee member will contact you at the e-mail listed on your application. Award Acceptance Requirements: If you are selected to receive assistance, you will receive an award letter and an acceptance agreement, which must be read, signed, and returned, via email. You will also need to provide a detailed invoice for services/program from the provider, a thank you note, a photo of the scholarship recipient, a :30 video of the scholarship recipient, and grant permission for the KNOWAutism Foundation to use the scholarship recipient's first name, photographic likeness, and video likeness in its publications, social media, website, fundraising materials, and/or other media before any payments are distributed. Incomplete applications will not be considered. Please note: all payments will be made directly to the service provider or school on behalf of the scholarship recipient. Only one (1) service/program may be requested per application, per individual.
Date of Application:*

MonthDayYear
Date
Do you live in the Greater Houston Area? The Greater Houston Area is defined as residing in one of the following counties: Austin, Brazoria, Chambers, Fort Bend, Galveston, Harris, Liberty, Montgomery and Waller.*
Is the scholarship applicant a US citizen? Please note we are only funding awards for US citizens at this time. *
Scholarship Applicant's Full Name:*

First NameLast Name
Scholarship Applicant's Date of Birth:*

MonthDayYear
Scholarship Applicant's Grade level:*
Scholarship Recipient's Gender/Sex:*
Date of Autism Spectrum Disorder Diagnosis (Diagnostic assessment required with this application):*

MonthDayYear
Please list all medical diagnosis/es:*
Has the scholarship applicant received therapeutic services prior to today? If yes, please list each type of therapy, how long the scholarship applicant received services for, the name of the provider, and any notes about each therapy/intervention. Please include if the services were provided by a public school or if by a professional not affiliated with a public school. The more information, the better. If no, enter N/A.*
If yes, do you have a current progress report for the scholarship applicant? If the scholarship applicant has received services prior, a current progress report is required with this application. *
Is the scholarship applicant verbal or non verbal?*
Grant amount requesting (Maximum award amount is $7500 per year):*
Parent/Guardian #1's Name (person completing this application):*

First NameLast Name
Parent/Guardian #1 email:*
example@example.com
Parent/Guardian #1 Cell Phone Number:*
Please enter a valid phone number.
Parent/Guardian #1's marital status:*
Parent/Guardian #1 Address: *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian #2's Name:*

First NameLast Name
Parent/Guardian #2 Address (if different from Parent/Guardian #1):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian #2 email:
example@example.com
Parent/Guardian #2 cell phone number:
Please enter a valid phone number.
Parent/Guardian #2's marital status (if not together w/Parent/Guardian #1:
Provider/Facility Name/Special Needs Specific School you are requesting the KNOWAutism scholarship to be paid to:*
Provider/Facility/School Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Provider/Facility/School Contact Name:*
Provider/Facility/School Phone Number:*
Please enter a valid phone number.
Provider/Facility/School Contact email:*
example@example.com
Has the scholarship applicant received services with this provider or attended school at this facility before? If currently enrolled, please provide how long they have been attending. *
For what year are you seeking assistance?*
Therapeutic Approach you are requesting assistance with (ABA, PRT, Speech, OT, PT, DIR, Private Special Education, etc.):*
Tuition/Fees Total in dollars- please include the time period services are for (ex. month, year, semester, school year, etc. Please note: an invoice/tuition statement for services is required with this application. All scholarships are paid directly to the provider of services for your child. For example, I want my son Jack to receive ABA therapy 5 days a week, for 6 months and each day is $50. The total tuition/fees would be $50/day x 5 days = $250/week. There are 52 weeks in a year and half of a year is 6 months/26 weeks. $250/week x 26 weeks = $6500. PLEASE NOTE: We do not fund supply fees at therapy clinics or private schools. *
Gross Annual Income for parent/guardian 1:*
Parent/Guardian 1's number of dependents (defined as a person you claim on your tax return as a legal dependent, usually a child under the age of 19. In some instances, children up to the age of 26 if enrolled in college may still qualify as a legal dependent. If you have legal guardianship over someone of any age (ex. aging parent, family member with special needs, etc., AND you claim them on your tax return, please include them in the number below). PLEASE DO NOT include yourself or your spouse. A copy of parent 1's tax return is required with this application):*
Do any of parent/guardian 1's other legal dependents have special needs? If so, please list their name(s), age(s), and diagnoses.*
Gross Annual Income for parent/guardian 2:*
Parent/Guardian 2's number of dependents (defined as a person they claim on their tax return as a legal dependent, usually a child under the age of 19. In some instances, children up to the age of 26, if enrolled in college, may still qualify as a legal dependent. If they have legal guardianship over someone of any age (ex. aging parent, family member with special needs, etc., AND claim them on their tax return, please include them in the number below). PLEASE DO NOT include them or their spouse. A copy of parent 2's tax return is required with this application unless Parent/Guardian #1 has sole custody ordered by a court of law or if parent/guardian #1 is married to parent/guardian #2). If parent/guardian #1 and #2 are married, please type N/A. :
Do any of parent/guardian 2's other legal dependents have special needs? If so, please list their name(s), age(s), and diagnoses. If parent/guardian #2 is married to parent/guardian #1, please type N/A.
If the parents/guardians are not legally married, does the other parent/guardian provide any type of financial assistance for the scholarship applicant? If the other parent/guardian is court ordered to provide child support and/or cover out of pocket medical expenses but does not currently pay, please include relevant information. If not applicable, please type N/A.*
If parents/guardians are unmarried to one and other, what is the court ordered custodial arrangement? *A certified court document outlining custodial arrangement is required with this application.*
If parents/guardians are not legally married, who has decision making authority for educational, medical and psychiatric treatment for the scholarship applicant? If legally married, enter N/A*
Does the scholarship applicant you are applying on behalf of currently receive SSI? *
If the child is receiving SSI, how much per month are they receiving? If not, please type N/A. A copy of the SSI award letter or official proof of monthly payments is required with this application.*
Has the scholarship applicant you are applying on behalf of received SSI in the past? If they have received SSI in the past but are not currently receiving this benefit, please explain. If the dependent has been approved for SSI but has not yet received payments, please include that information. If not applicable, please enter N/A.*
Do you currently receive SNAP benefits?*
Is either parent/guardian legally disabled and receiving disability benefits?*

Yes, I and/or parent guardian #2 is legally disabled and am receiving disability benefits.No, neither parent/guardian is not legally disabled.Yes, I and/or parent guardian #2 is legally disabled, but are not receiving any benefits.Yes, I and/or parent guardian #2 is legally disabled and have received disability benefits in the past, but am not currently.
If either parent/guardian is receiving benefits, please list the amount and frequency. If not, please type N/A. *
Is parent/guardian 2 legally disabled and receiving disability benefits?

Yes, parent 2 is legally disabled and is receiving disability benefits.No, parent 2 is not legally disabled.Yes, parent 2 is legally disabled, but is not receiving any benefits.Yes, parent 2 is legally disabled, has received disability benefits in the past, but is not currently receiving any disability benefits.I do not know if parent 2 is receiving disability benefits.
What other types of financial assistance does parent/guardian 1 & 2 receive? Please include all financial assistance from the government, family, friends, place of worship, significant others, etc. This includes the source and the amount per month you are receiving. (Please note: Receiving assistance from additional sources does not necessarily go against the scholarship applicant. The grants committee is looking for a wholistic view of your financial situation. We applaud parents/guardians who are resourceful and are doing everything they can to provide for the scholarship applicant.):*
Is there a court order in place requiring the other parent/guardian to pay child support or medical support? If yes, a payment record showing the last payment date and amount is required. This can be found online at https://childsupport.oag.texas.gov/s/login/?language=en_US&ec=302&startURL=%2Fs%2F*
If the other parent is court ordered to pay child support and or medical support, please enter the amount per month they are required to pay. Please enter the total amount they are court ordered to pay per month even if they are not currently paying. If this does not apply, please type N/A. *
What is your current living situation?*

Own HomeRent Home/Apartment/ResidenceLive with familyLive with boyfriend/girlfriend or other person you are not legally married to (does not include family)Live in government subsidized housingOther
If other, please explain.
Monthly rent/mortgage*
Is the scholarship applicant currently covered by private medical insurance (not including Medicaid)? Typically, this insurance is offered through a parent's employer or the Healthcare Marketplace/Obamacare.*
If yes, what type of medical insurance plan is the scholarship applicant covered under (not including Medicaid)?*
Name of insurance company (not including Medicaid; a copy of the front and back of the insurance card is required with this application):
Primary insured's Name:
Deductible:
Co-Pay
In network out of pocket max:
Out of network out of pocket max:
Is the scholarship applicant enrolled in more than one private medical insurance plan (not including Medicaid)? This typically happens if both parents have different medical insurance plans and the child is covered on both. *
If the scholarship applicant is enrolled in more than one medical insurance plan not including Medicaid, please provide the name of the insurance carrier, type of insurance (HMO, PPO, POS), primary insured's name, deductible, In Network Out of Pocket Max, Out of Network Out of Pocket Max, co-pay, etc. If not, please type N/A. *
Is the scholarship applicant currently enrolled with Medicaid in Texas? *
If yes, what plan is the scholarship applicant currently enrolled in? *
Are any of the services you are requesting financial assistance with covered by medical insurance (not Medicaid)?*
If yes, is the provider you are seeking assistance with in network? *
If the services are covered by medical insurance (not Medicaid), what is your total expected out of pocket for the services you are requesting assistance for? Please include the time frame of the services you're requesting assistance to cover (month, week, semester, school year, etc.) If not applicable, please enter N/A.*
Describe your particular financial situation and why you are seeking financial assistance. Please include any details if your financial situation has changed within the last 6-12 months. Detailed responses are encouraged.*
Have you applied for financial aid, scholarships, grants, or other financial assistance from any other organizations or agencies to cover any part of the requested services? This includes financial aid for private school, grants from therapy clinics or providers, and/or other subsidies.*
If yes, please include the names of the entities from which you have applied, the date, and the amount of assistance requested. If not applicable, please enter N/A.*
If you have been awarded financial assistance from another entity to cover any part of this request, please list the name(s), amount(s), and time period(s). If not applicable, please enter N/A.*
Has the scholarship applicant previously received a grant from the KNOWAutism Foundation?*
If yes, list year(s) and amount(s) awarded:
How did you hear about our grant/scholarship program? Please be specific. *
Has the child been accepted into the program/school/therapy clinic for which you are requesting financial assistance? For a therapy clinic/provider, this includes having completed and been formally approved or denied services through medical insurance and not being on a wait list. For private school, this means that the applicant has completed the entire application process and has been accepted. ALL INDIVIDUALS MUST HAVE COMPLETED THE ENROLLMENT PROCESS AND BEEN ACCEPTED BEFORE ANY FINANCIAL ASSISTANCE WILL BE AWARDED. *
By signing this form, you certify that all answers provided are true and complete to the best of your knowledge. I understand that incomplete applications will not be considered. I understand knowingly providing false information will disqualify my family from consideration for all current and future grants offered by the KNOWAutism Foundation. I grant permission for the KNOWAutism Foundation to contact individuals and entities listed on this application for verification and to collect additional information, if needed. I understand a maximum of one application per scholarship applicant may be submitted every twelve (12) months from the date of the last application. I understand I may withdraw my application, at any time, in writing to info@know-autism.org.
Signature*

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Full Name*
Today's Date*

MonthDayYear
Diagnostic Assessment *

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Tuition or Therapy Services Invoice*

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Parent/Guardian #1's 2022 Tax Return (social security numbers may be redacted):*

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Parent/Guardian #2's 2022 Tax Return (social security numbers may be redacted):

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Medical Insurance Card for scholarship applicant (front):

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Medical Insurance Card for scholarship applicant (back):

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Medicaid Card for scholarship applicant (front):

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Certified Divorce Decree/Custodial Agreement:

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Current IEP Plan

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Progress Report*

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Other (anything additional you'd like considered):

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Proof of child support payments (or lack thereof)

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Proof of SSI payments/award letter for child

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Should be Empty:

Tuition and Therapy Assistance Application

Eligibility Requirements